Toward Improving the Outcome of Pregnancy III pot

Barfield, MD, MPH Director, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion Centers for Medicare and Medicaid Services CMS Lekisha

Toward Improving

the Outcome

of Pregnancy III

Enhancing Perinatal Health Through Quality,

Safety and Performance Initiatives

William Oh, MD, FAAP, Chair

Professor, Department of Pediatrics, Warren Alpert Medical School

of Brown University Women and Infants’ Hospital Providence, RI

Scott D Berns, MD, MPH, FAAP

Senior Vice President, Chapter Programs, March of Dimes Foundation,

National Office White Plains, NY Clinical Professor, Department of Pediatrics Warren Alpert Medical School

of Brown University Providence, RI

Ann Scott Blouin, RN, PhD

Executive Vice President, Accreditation and Certification Operations The Joint Commission

Oakbrook Terrace, IL

Deborah E Campbell, MD, FAAP

Director, Division of Neonatology Children’s Hospital at Montefiore Professor of Clinical Pediatrics Associate Professor of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine New York, NY

Alan R Fleischman, MD

Senior Vice President and Medical Director, March of Dimes Foundation,

National Office White Plains, NY Clinical Professor of Pediatrics and Clinical Professor of

Epidemiology & Population Health Albert Einstein College of Medicine New York, NY

Paul A Gluck, MD

Associate Clinical Professor, Obstetrics and Gynecology

University of Miami Department of Obstetrics and Gynecology Miller School of Medicine

Miami, FL

Margaret E O’Kane

President National Committee for Quality Assurance Washington, DC

Anne Santa-Donato, RNC, MSN

Director, Childbearing and Newborn Programs Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) Washington, DC

Kathleen Rice Simpson, PhD, RNC, FAAN

Perinatal Clinical Nurse Specialist,

St John’s Mercy Medical Center

St Louis, MO

Ann R Stark, MD

Professor of Pediatrics Baylor College of Medicine Houston, TX

John S Wachtel, MD, FACOG

Obstetrician Gynecologist Menlo Medical Clinic, Menlo Park, CA Adjunct Clinical Professor Department of Obstetrics and Gynecology Stanford University School of Medicine Stanford, CA

TIOP III Steering Committee

TIOP III Staff

Scott D Berns, MD, MPH, FAAP, Editor Andrea Kott, MPH, Consulting Editor

Nicole DeGroat Kimberly Paap Kelli Signorile

Preface: View from the Chair ii

Acknowledgements iii

TIOP III Advisory Group iv

Authors v

Executive Summary ix

Foreword xi

Chapter 1: History of the Quality Improvement Movement 1

Chapter 2: Evolution of Quality Improvement in Perinatal Care 9

Chapter 3: Epidemiologic Trends in Perinatal Data 19

Chapter 4: The Role of Patients and Families in Improving Perinatal Care 33

Chapter 5: Quality Improvement Opportunities in Preconception and Interconception Care 45

Chapter 6: Quality Improvement Opportunities in Prenatal Care 55

Chapter 7: Quality Improvement Opportunities in Intrapartum Care 65

Chapter 8: Applying Quality Improvement Principles in Caring for the High-Risk Infant 75

Chapter 9: Quality Improvement Opportunities in Postpartum Care 87

Chapter 10: Quality Improvement Opportunities to Promote Equity in Perinatal Health Outcomes 101

Chapter 11: Systems Change Across the Continuum of Perinatal Care 111

Chapter 12: Policy Dimensions of Systems Change in Perinatal Care 123

Chapter 13: Opportunities for Action and Summary of Recommendations 135

Leaders in perinatal health collaborated on this effort and introduced a model system for regionalized perinatal care, including definitions of levels of hospital care, which led to the template for perinatal regional-ization and improved perinatal outcomes

Endorsement of this document by key professional organizations ensured the implementation of the concepts advanced

by TIOP I Regionalization of care, along with evidenced-based therapeutic interven-tions (assisted ventilation, antenatal corti-costeroids, etc.), contributed to the marked improvement in neonatal survival rates during the ensuing two decades

Despite these accomplishments, the March

of Dimes saw the need for further ment and, in 1993, it published TIOP II, which emphasized the importance of the per-inatal continuum of care, from preconcep-tion through infancy TIOP II appeared just when the importance of quality improvement

improve-in U.S health care was gaimprove-inimprove-ing attention

This third volume, Toward Improving the

Outcome of Pregnancy: Enhancing natal Health Through Quality, Safety and Performance Initiatives (TIOP III), picks up

Peri-where the first two volumes left off

It is not meant to be a comprehensive textbook on perinatal health, but rather an action-oriented monograph that highlights proven principles and methodologies, as well as selected safety initiatives and quality improvement programs, that you can imple-

ment now that may significantly improve perinatal outcomes in your practice setting Many individuals and organizations came together to produce TIOP III A Steering Committee was responsible for the overall direction of TIOP III and was comprised

of experts from the American Academy of Pediatrics, The American College of Obste-tricians and Gynecologists, the Association

of Women’s Health, Obstetric and Neonatal Nurses, The Joint Commission, the National Committee for Quality Assurance, and the March of Dimes Also, an Advisory Group, made up of additional organizations, com-mitted to assisting with dissemination of the findings of TIOP III

It has been deeply satisfying and an honor

to witness and participate in the tremendous advances in perinatal care during the past

50 years The March of Dimes, through its efforts in publishing the three TIOP documents and its initiatives dedicated to improving the health of babies, preventing prematurity and integrating family-centered care into NICUs, has made a profound con-tribution to improving pregnancy outcomes

I am certain that TIOP III will enhance pregnancy outcomes through collaborative, perinatal quality improvement in the years

to come

William Oh, MD, Chair, TIOP III Steering Committee

Preface: View from the Chair

After witnessing the emergence and dramatic progress in perinatal medicine and improvement in pregnancy outcomes during the past half century, it is a distinct honor and pleasure to introduce this document In the early 1970’s, a report from Canada showed that neonatal mortality was significantly lower in obstetric facilities with neonatal intensive care units (NICUs) compared to those without This finding emphasized the importance of an integrated system that would promote delivery of care to mothers and infants based on the level of acuity

The concept prompted the March of Dimes, in 1976, to publish Toward

Improving the Outcome of Pregnancy (TIOP I).

In particular, I thank Andrea Kott,

Consulting Editor, for her steadfast

com-mitment that ensured this document would

come to fruition I also thank the TIOP III

staff who were vital to all aspects of the

preparation of this document, including the

coordination of e-mails, mailings,

confer-ence calls and meetings: Nicole DeGroat;

Kimberly Paap; Kelli Signorile; and Ann

Umemoto I especially thank all of the

authors for their expertise and

contribu-tions to the monograph In addition, thanks

to the members of the TIOP III Advisory

Group who provided essential feedback and

are helping to disseminate the

recommenda-tions provided within TIOP III

Thanks to the following March of Dimes staff for their varied and significant contri-butions:

Diane Ashton; Lisa Bellsey; Vani

Bettegow-da and the March of Dimes Perinatal Data Center; Janis Biermann; Gerard Carrino;

Anne Chehebar; Todd Dezen; Sean Fallon;

Ray Fernandez; Angela Gold; Judi Gooding;

Sabine Jean-Walker; Amanda Jezek; Barbara Jones; Michele Kling; Alison Knowings;

Elizabeth Lynch; Michelle Miller; Carolyn Mullen; John Otero; Judith Palais; David Rose; Beth St James; Doug Staples; Marina Weiss; and Emil Wigode Finally, I thank Jennifer Howse, President of the March of Dimes, whose vision and support made this third volume of TIOP a reality

Scott D Berns, MD, MPH, FAAP Editor, TIOP III

Acknowledgements

I am indebted to the many colleagues who contributed to this monograph Thanks

to William Oh, Chair of the TIOP III Steering Committee, for his inspiration and

leadership Thanks to the Steering Committee, who met numerous times over the

course of 17 months in person, over the phone, and via e-mail: Ann Scott Blouin;

Deborah Campbell; Alan Fleischman; Paul Gluck; Margaret O’Kane; Anne

Santa-Donato; Kathleen Rice Simpson; Ann Stark; and John Wachtel In addition, thanks

to Hal Lawrence, ACOG Vice President, Practice Activities, for his support and

input throughout the development of this monograph

Agency for Healthcare Research and Quality

Beth Collins Sharp Senior Advisor for Women’s Health and Gender Research

American Academy of Family Physicians

Carl R Olden, MD, FAAP Vice Chair of Advisory Board of AAFP, Advanced Life Support in Obstetrics Program (ALSO)

American College of Nurse Midwives

Tina Johnson, CNM, MS Director of Professional Practice and Health Policy

American Hospital Association

Beth Feldpush, PhD Senior Associate Director, Policy Bonnie Connors Jellon, MHSA Director, AHA Section for Maternal Child Health

American Public Health Association

Georges C Benjamin, MD, FACP, FACEP Executive Director

America’s Health Insurance Plans

Karen Ignagni President and Chief Executive Officer

Association of Maternal and Child Health Programs

Michael Fraser, PhD Chief Executive Officer

Centers for Disease Control and Prevention

CAPT Wanda D Barfield, MD, MPH Director, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion

Centers for Medicare and Medicaid Services (CMS)

Lekisha Daniel-Robinson, MPH Center for Medicaid, CHIP and Survey &

Certifications (CMCS), Division of Quality, Evaluation, and Health Outcomes

Health Resources and Services Administration

Christopher DeGraw, MD Deputy Director, Division of Research, Training and Education

Institute for Healthcare Improvement

Sue Leavitt Gullo, RN, MS, BSN Managing Director

Director, Labor and Delivery, Maternity, Lactation Services, Childbirth and Family Education, Infant Loss Program,

Elliott Hospital and Director

National Association of Children’s Hospitals and Related Institutions

Sandy McElligott, MBA, RN, CNA, BC Senior Vice President/Chief Nursing Officer, Texas Children’s Hospital

National Association of Neonatal Nurses

Lori Armstrong, MS, RN President

National Business Group on Health

Cynthia Tuttle, PhD, MPH Vice President,

Center for Prevention and Health Services

National Hispanic Medical Association

Diana E Ramos, MD, MPH, FACOG Leadership Fellow

Associate Professor in OB/GYN University of Southern California Keck School of Medicine

National Initiative for Children’s Healthcare Quality

Karthika Streb Senior Project Manager and Director of Program Management and Staffing

National Institute of Child and Human Development

Lisa Kaeser Program Analyst

National Medical Association

Ivonne Fuller Bertrand, MPA Associate Executive Director

National Partnership for Women and Families

Lee Partridge Health Policy Advisor

National Perinatal Association

Mary Anne Laffin, Midwife President-Elect

National Perinatal Information Center

Janet H Muri, MBA President

TIOP III Advisory Group

The contents of this

monograph and the

recommendations

and opinions

expressed are those

of the authors and

which the authors

are affiliated or the

members of the

Advisory Group.

Marie R Abraham, MA

Senior Policy and Program Specialist

Institute for Patient- and

Family-Centered Care

Bethesda, MD

Diane M Ashton, MD, MPH, FACOG

Deputy Medical Director

March of Dimes Foundation, National Office

White Plains, NY

Assistant Clinical Professor, Department

of Obstetrics & Gynecology

SUNY Downstate Medical Center

New York, NY

Maribeth Badura, RN, MSN*

Former Director of Health Resources and

Services Administration (HRSA)

Maternal Child Health Bureau’s

Division of Healthy Start and

Perinatal Services

Bethesda, MD

Wanda D Barfield, MD, MPH, FAAP

Director, Division of Reproductive Health

Centers for Disease Control and Prevention

Director, Maternal-Fetal Medicine

Thomas Jefferson University

Scott D Berns, MD, MPH, FAAP

Senior Vice President, Chapter Programs March of Dimes Foundation, National Office White Plains, NY

Clinical Professor, Department of Pediatrics Warren Alpert Medical School of Brown University

Providence, RI

Vani R Bettegowda, MHS

Acting Director, Perinatal Data Center March of Dimes Foundation, National Office White Plains, NY

Eric Bieber, MD

System Chief Medical Officer University Hospitals

Cleveland, OH

Ann Scott Blouin, RN, PhD

Executive Vice President Accreditation and Certification Operations The Joint Commission

Oakbrook Terrace, IL

Deborah E Campbell, MD, FAAP

Director, Division of Neonatology Children’s Hospital at Montefiore New York, NY

Professor of Clinical Pediatrics Associate Professor of Obstetrics

& Gynecology and Women’s Health Albert Einstein College of Medicine New York, NY

Joanna F Celenza, MA, MBA

March of Dimes/CHaD ICN Family Resource Specialist Children’s Hospital at Dartmouth-Hitchcock Medical Center Lebanon, NH

*deceased

National Quality Forum

Janet M Corrigan, PhD

President and Chief Executive Officer

Pediatrix/Obstetrix Medical Group

Alan Spitzer, MD

Senior Vice President and Director,

Center for Research and Education

Society for Maternal-Fetal Medicine

Daniel O’Keefe, MD Executive Vice President

Vermont Oxford Network

Jeffrey D Horbar, MD Chief Executive & Scientific Officer

President The Joint Commission Oakbrook Terrace, IL

Steven L Clark, MD, FACOG

Medical Director, Women’s and Children’s Clinical Services

Hospital Corporation of America Nashville, TN

James W Collins, Jr., MD, MPH

Medical Director Neonatal Intensive Care Unit Children’s Memorial Hospital Chicago, IL

Professor, Department of Pediatrics Northwestern University

Feinberg School of Medicine Chicago, IL

Raymond Cox, MD, MBA

Chairman, Department of Obstetrics and Gynecology Saint Agnes Hospital Baltimore, MD

Karla Damus, PhD, MSPH, MN, RN, FAAN

Clinical Professor, School of Nursing Bouvé College of Health Sciences Northeastern University

Boston, MA

Diana L Dell, MD

Assistant Professor Emeritus Department of Psychiatry Duke University Medical Center Durham, NC

Siobhan M Dolan, MD, MPH

Associate Professor Department of Obstetrics

& Gynecology and Women’s Health Albert Einstein College of Medicine/

Montefiore Medical Center New York, NY

Edward F Donovan, MD

Co-Lead, Ohio Perinatal Quality Collaborative James M Anderson Center for Health Systems Excellence

Cincinnati Children’s Hospital Medical Center

Cincinnati, OH Professor of Clinical Pediatrics University of Cincinnati College of Medicine Cincinnati, OH

Principal Premier Consulting Solutions Charlotte, NC

Alan R Fleischman, MD

Senior Vice President and Medical Director March of Dimes Foundation, National Office White Plains, NY

Clinical Professor of Pediatrics and Clinical Professor of

Epidemiology & Population Health Albert Einstein College of Medicine New York, NY

Margaret Comerford Freda, EdD, RN, CHES, FAAN

Editor, MCN The American Journal of Maternal Child Nursing

Professor of Clinical Obstetrics &

Gynecology and Women’s Health New York, NY

Paul A Gluck, MD

Associate Clinical Professor, Obstetrics and Gynecology

University of Miami Department of Obstetrics and Gynecology Miller School of Medicine

Miami, FL

Jeffrey B Gould, MD, MPH

Director, Perinatal Epidemiology and Health Outcomes Research Unit Stanford University Medical Center Stanford, CA

Robert L Hess Professor of Pediatrics Division of Neonatal

and Developmental Medicine Stanford University School of Medicine Stanford, CA

Gary D.V Hankins, MD

Professor and Chairman Department of Obstetrics & Gynecology University of Texas Medical Branch Galveston, TX

Jeffrey D Horbar, MD

Chief Executive and Scientific Officer Vermont Oxford Network

Burlington, VT Jerold F Lucey Professor of Neonatal Medicine

University of Vermont College of Medicine Burlington, VT

Authors Jay D Iams, MD

Frederick P Zuspan Professor

& Endowed Chair

Division of Maternal Fetal Medicine

Department of Obstetrics & Gynecology

The Ohio State University College of

Medicine

Columbus, OH

Beverly H Johnson

President and Chief Executive Officer

Institute for Patient-

and Family-Centered Care

Bethesda, MD

Carole A Kenner, PhD, RNC-NIC, FAAN

President

Council of International Neonatal Nurses, Inc

Dean/Professor School of Nursing

Eric Knox, MD, FACOG

Chief of OB Risk & Safety Officer

Chief, Maternal & Infant Health Branch

Division of Reproductive Health

National Center for Chronic Disease

Prevention and Health Promotion

Centers for Disease Control & Prevention

Atlanta, GA

George A Little, MD

Neonatal/Perinatal Medicine

Dartmouth-Hitchcock Medical Center

Professor of Pediatrics and of Ob/Gynecology

Dartmouth Medical School

Hanover, NH

Michael C Lu, MD, MPH

Associate Professor, Obstetrics and Gynecology Associate Director, Child and Family Health Training Program

University of California at Los Angeles Los Angeles, CA

Barbara S Medoff-Cooper, RN, PhD, FAAN

Professor University of Pennsylvania, School of Nursing Philadelphia, PA

Merry-K Moos, RN, FNP, MPH, FAAN

Research Professor (retired) Department of Obstetrics and Gynecology University of North Carolina at Chapel Hill Raleigh, NC

Janet H Muri, MBA

President National Perinatal Information Center Providence, RI

William Oh, MD, FAAP

Professor, Department of Pediatrics Warren Alpert Medical School of Brown University

Women and Infants’ Hospital Providence, RI

Margaret E O’Kane

President National Committee for Quality Assurance Washington, DC

Bryan T Oshiro, MD

Vice Chairman and Associate Professor Department of Obstetrics and Gynecology Loma Linda University School of Medicine Loma Linda, CA

Joann R Petrini, PhD, MPH

Assistant Director of Research Danbury Hospital

Danbury, CT Associate Clinical Professor, Obstetrics &

Gynecology and Women’s Health Albert Einstein College of Medicine New York, NY

Samuel F Posner, PhD

Editor in Chief, Preventing Chronic Disease Deputy Associate Director for Science National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Atlanta, GA

Program Director Lancaster General Hospital Family Medicine Residency

Lancaster, PA Clinical Associate Professor Temple University School of Medicine Philadelphia, PA

Clinical Associate Professor Penn State College of Medicine Hershey, PA

Nancy Jo Reedy, RN, CNM, MPH, FACNM

Director of Nurse-Midwifery Services Texas Health Care, PLLC

Kathleen Rice Simpson, PhD, RNC, FAAN

Perinatal Clinical Nurse Specialist

St John’s Mercy Medical Center

Bruce C Vladeck, PhD

Senior Advisor Nexera Inc

New York, NY

John S Wachtel, MD, FACOG

Obstetrician Gynecologist Menlo Medical Clinic, Menlo Park, CA Adjunct Clinical Professor Department of Obstetrics and Gynecology Stanford University School of Medicine Stanford, CA

Each chapter explores the elements that are

essential to improving quality, safety and

performance across the continuum of

peri-natal care: consistent data collection and

measurement; evidence-based initiatives;

adherence to clinical practice guidelines; a

life-course perspective; care that is patient-

and family-centered, culturally sensitive

and linguistically appropriate; policies that

support high-quality perinatal care; and

systems change

As TIOP III demonstrates, improving the

quality of perinatal care depends on

apply-ing evidence-based practice and clinical

guidelines throughout the course of a

wom-an’s life This means screening and

monitor-ing for conditions that could compromise

a healthy pregnancy long before a woman

ever considers becoming pregnant; it means

taking a comprehensive, culturally sensitive,

linguistically and developmentally

appropri-ate approach to a woman’s preconception,

prenatal, interconception and postpartum

care, considering biological, emotional, as

well as socioeconomic factors that could

influence her health and her access to health

care services

Many of these evidence-based practices —

CenteringPregnancy®, Kangaroo Care and

exclusive breastmilk feeding — have been

shown to improve perinatal health

out-comes by empowering patients: positioning

them, their newborns and their families at

the center of their care and making them an integral part of their health care decision-making team

Each chapter of TIOP III illustrates specific strategies and interventions that incorporate robust process and systems change, including the power of statewide quality improvement collaboratives that are improving perinatal outcomes And it concludes with cross-cutting themes and action items that stakeholders across the continuum of perinatal care will recognize

as opportunities to improve pregnancy outcomes

Executive Summary

Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health

Through Quality, Safety and Performance Initiatives (TIOP III) is a call to action

It is a tool for anyone committed to the enhancement of perinatal health:

clini-cians on the frontline, as well as public health professionals, researchers, payers,

policy-makers, patients and families TIOP III is filled with examples of promising

and successful initiatives at hospitals and health care systems across the country,

designed to improve the quality of perinatal care

• Assuring the uptake of robust perinatal quality improvement and safety initiatives

• Creating equity and decreasing disparities

in perinatal care and outcomes

• Empowering women and families with information to enable the development

of full partnerships between health care providers and patients and shared decision-making in perinatal care

• Standardizing the regionalization of perinatal services

• Strengthening the national vital statistics system

Summary of TIOP III Cross-Cutting Themes

Andrea Kott and Scott D Berns

continued

Ultimately, reaching a more efficient, more accountable system of perinatal care will require a level of collaboration, services integration and communication that lead

to successful perinatal quality improvement initiatives, many of which are described throughout this book In addition to the consistent collection of data and measure-ment and the application of evidence-based interventions, successful collaborations, like

all perinatal quality improvement, depend on the engagement, support and commitment

of everyone reading this book: health care professionals and hospital leadership, public health professionals and community-based service providers, research scientists, policy-makers and payers, as well as patients and families TIOP III is the call to action and the tool that can inspire and guide their efforts toward improving the outcome of pregnancy

Summary

TIOP I also galvanized the March of Dimes

leadership to intensify its support for

neo-natal research, regional neoneo-natal intensive

care unit (NICU) centers, neonatal nursing

education, intensive care nurseries,

nurse-midwife education, community health teams

and genetic counseling

Subsequently, through research

break-throughs such as surfactant therapy,

con-tinued development of lifesaving NICU

technology and improved systems

accom-plished through regionalization, infant

mortality has continued a steady decline to

the present day

Nevertheless, maternal health issues

such as lack of health insurance, poverty,

substance abuse, unintended pregnancy and

other behavioral and social barriers

con-tinued to hamper the Foundation’s efforts

to improve birth outcomes As a result, the

Foundation turned its attention to

improv-ing care durimprov-ing pregnancy and birth through

proven risk-reduction strategies and the

establishment of perinatal boards, to better

ensure accountability within regionalized

systems of care This became the framework

for TIOP II, Toward Improving the

Out-come of Pregnancy: The 90s and Beyond,

which a second Committee on Perinatal Health issued in 1993

The March of Dimes put TIOP II to work at the grassroots level through the Campaign for Healthier Babies, a 1990 initiative that addressed improved access to

prenatal care and, Think Ahead!, in 1995,

a nationwide campaign that emphasized preconception care, healthy lifestyles and the importance of folic acid

Both the 1972 and 1990 Committees on Perinatal Health aimed to reduce rates of maternal and infant mortality and morbid-ity in the United States But one negative birth outcome began to receive increased scrutiny within the Foundation, and that was the relentless increase in the nation’s rate of premature birth since TIOP I The March of Dimes responded to this alarming trend by launching a comprehensive nation-

al Prematurity Campaign in 2003

The Foundation has since attacked the issue of premature birth by raising politi-cal and public visibility for this problem, supporting cutting-edge research and exploring clinical, educational and public health interventions designed to achieve the widest impact These include the March of

Foreword

Toward Improving the Outcome of Pregnancy III has an illustrious past It began

in 1972, when the March of Dimes, newly dedicated to the burgeoning field of

perinatology, created the Committee on Perinatal Health and asked it to

iden-tify critical issues and develop guidelines and recommendations for the care of

pregnant women and newborns with a special focus on infant mortality Just four

years later, in 1976, the committee released Toward Improving The Outcome of

Pregnancy (TIOP I), a book that synthesized the efforts of four organizations (The

American College of Obstetricians and Gynecologists, the American Medical

Association, the American Academy of Pediatrics, and the American Academy of

Family Physicians) and revolutionized the system of perinatal hospital care by

rec-ommending systematized, cohesive regional networks of hospitals, each assigned

to one of three levels of inpatient care based on patient risks and needs

Dimes NICU Family Support® program and

“Healthy Babies Are Worth the Wait®”,

a prematurity-prevention partnership in Kentucky Preliminary data from the National Center for Health Statistics show that for the first time in 30 years, rates of premature birth have declined in 2007

as well as 2008, most recently from 12.7 percent (2007)1 to 12.3 percent (2008).2 But we must continue to seek solutions if these small gains are to be preserved and accelerated And solutions may be at hand

Most recently, two Institute of Medicine

(IOM) reports — To Err Is Human:

Build-ing a Safer Health Care System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001) —

revealed the high rate of preventable errors

in hospitals and the extreme complexity of systems that underlie most of those errors

As a result, there has been growing est in the perinatal community in applying

inter-quality improvement strategies to prevent errors and to reduce the rate of prematurity Based on a subsequent IOM report,

Preterm Birth: Causes, Consequences, and Prevention, we now know that preterm

birth costs our nation $26 billion annually

in health and medical costs.3 Preventing preterm birth, through quality improve-ment approaches, offers an unprecedented opportunity to both bend the cost curve and

to improve the outcome of pregnancy.The March of Dimes is hopeful that this

third volume, TIOP III: Toward Improving

the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives, will drive the

implementation of model programs and quality improvement initiatives and will increase transparency and accountability for consumers — all of which can support improved pregnancy outcomes

References

1 Martin JA, Hamilton BE, Sutton PD, et al Births: Final Data for 2007 Natl Health Stat Report 2010;58

2 Hamilton BE, Martin JA, Ventura SJ Division of Vital Statistics Births: Preliminary Data for

2008 Natl Health Stat Report 2010;58

3 Behrman R, Stith Butler A eds Preterm Birth: Causes, Consequences, and Prevention

Washington, DC: The National Academies Press, 2007

Dr Jennifer L Howse President

March of Dimes

History of the Quality

Improvement

Movement

Mark R Chassin and Margaret E O’Kane

Chapter

A continent away, concern about the state

of American medicine mounted In 1847, the American Medical Association (AMA) emerged, in response to the need for a tougher, standardized medical education system Medical education and the prac-tice of medicine in colonial America were haphazard at best According to Paul Starr,

in The Social Transformation of American

Medicine, “All manner of people took up

medicine in the colonies and ated the title of doctor…,” including “a Mrs Hughes, who advertised in 1773 that besides practicing midwifery, she cured

appropri-‘ringworms, scald heads, piles, worms’ and also made ladies’ dresses and bonnets in the newest fashion.” During the American Revolution, 400 of the nation’s estimated 3,500 to 4,000 physicians had formal medical training, and only half held medical degrees, which weren’t worth much, since they required, at most, only 6 to 8 months

of medical school and 3 years of ticeship And yet, medical school diplomas often were accepted as licenses to practice medicine.3

appren-In its drive to reform medical education, the AMA in 1904 created the Council on Medical Education, which asked the Car-negie Foundation for the Advancement of Teaching to conduct a study of medical schools The Foundation assigned the study

to education expert Abraham Flexner, who

wrote in his 1910 report, Medical Education

in the United States and Canada, “Touted

laboratories were nowhere to be found, or consisted of a few vagrant test tubes squir-reled away in a cigar box; corpses reeked because of the failure to use disinfectant in the dissecting rooms Libraries had no books; alleged faculty members were busily occu-pied in private practice Purported require-ments for admission were waived for anyone who would pay the fees.”3

Chapter 1:

History of the Quality Improvement Movement

Early Effects to Improve Clinical Care and Medical Education

The evolution of quality improvement has been a steady response to the need

to correct errors Consider Florence Nightingale, a public health pioneer who addressed the link between paltry hospital sanitation and the high — 60 percent

— fatality rate among wounded soldiers during the Crimean War of 1854 Germ theory was gaining traction in Europe and pointing to the link between high morbidity and mortality rates and the lack of basic sanitation and hygiene standards Nightingale, while serving as a nurse at the Barrack Hospital in Istanbul, developed practices — hand washing, sanitizing surgical tools, regu-larly changing bed linens and making sure all wards were clean — that are standard in hospitals today She also promoted good nutrition and fresh air

By the time this forerunner of evidence-based medicine left Barrack Hospital, mortality had plummeted to 1 percent.1,2

Mark R Chassin and Margaret E O’Kane

Medical education underwent dramatic

transformation after the publication of

Flexner’s report Many schools closed,

some consolidated, and all tightened their

entrance requirements Length of study and

training increased and incorporated

biomed-ical studies in biology, chemistry and

phys-ics with strict, supervised clinical training.4

While just 50 percent of medical school

graduates moved on to hospital training in

1904, an estimated 75 to 80 percent were

taking internships by 1912.3

As Flexner’s report revolutionized the

medical education system, Ernest Codman,

a surgeon from Harvard Medical School

and Massachusetts General Hospital,

applied his “End Result System of

Hos-pitalization Standardization Program,” a

three-step approach to quality assurance, to

improving hospital care Codman’s system

used quality measures to determine if

prob-lems stemmed from patients, the health care

system or clinicians; quantified the lack of

quality; and, remedied problems to

pre-vent them from happening again.5 In 1917,

the American College of Surgeons (ACS)

adopted his “End Result System” for its

Hospitalization Standardization Program,

which set minimum standards for hospital

care These standards required that, among

other things: all hospital physicians are

well-trained, competent and licensed; staff

meetings and clinical reviews occur

regu-larly; and, that medical histories, physical

exams and laboratory tests are recorded.6

In 1918, the ACS began using its newly

established minimum standards to inspect

hospitals Of 692 hospitals, only 89 met the

minimum standards However, by 1950,

the Hospitalization Standardization

Pro-gram approved more than 3,200 hospitals.7

Improvements to Maternal Child

Health Trigger Other Efforts

While much concern about health care

quality in the early 20th century revolved

around hospitals, America’s high maternal

and infant mortality rates, longtime

indica-tors of quality, were also claiming attention

In 1921, Congress passed the Towner Act, which granted states funds

Sheppard-to improve access Sheppard-to maternal and child health services In 1935, Congress passed Title V of the Social Security Act, to equip and finance pediatric and primary care services for hospitals in underserved areas

The Emergency Maternity and Infant Care program followed, financing care for 1.5 million women and infants of United States soldiers during World War II And, in 1946 came the Hill-Burton Act, which awarded grants to states to build hospitals.8

Efforts to provide women, children and the underserved with more and better care led to the creation of numerous programs, including Medicare and Medicaid

By the mid-1900s, improving the quality

of health and hospital care was an idea with

a century of effort behind it It was after World War II, however, when the concepts

of modern quality improvement emerged, initially focusing not on health outcomes but on systems change in business and industry

The Revolution of Quality Improvement in Business and Industry

Beginning in the mid 1920s, Walter A

Shewhart and W Edwards Deming, both physicists, and Joseph M Juran, an engi-neer, laid the groundwork for modern qual-ity improvement In their efforts to increase the efficiency of American industry, they concentrated on streamlining production processes, while minimizing the opportunity for human error, forging important qual-ity improvement concepts like standard-izing work processes, data-driven decision making, and commitment from workers and managers to improving work practices.6 These elements of systems change, first applied to business and industry, ultimately trickled down to the American health care system as awareness of its need for improve-ment grew.9-12

Florence Nightingale, while serving as a nurse

at the Barrack Hospital in Istanbul, developed practices — hand washing, sanitizing surgical tools, regularly changing bed linens and making sure all wards were clean

— that are standard

in hospitals today

History of the Quality Improvement

Movement

of Hospitals as a not-for-profit tion to provide voluntary accreditation to hospitals Early on, The Joint Commission used the minimum standards of ACS’s Hospital Standardization Program to evaluate hospitals In time, however, The Joint Commission, which became The Joint Commission on Accreditation of Healthcare Organizations in 1987, adopted more rigor-ous standards, which reflected the struc-ture-process-outcomes model that Avedis Donabedian presented in his 1966 article,

organiza-Evaluating the Quality of Medical Care.

Who provides care and where (structure);

how care is provided (process); and the sequences of care (outcomes) are all needed

con-to measure quality, Donabedian argued.13

By the mid-1990s, The Joint Commission introduced into the accreditation process the elements of system change derived from the work of Deming, Shewhart and Juran:

the role of organizational leadership, data- driven decision making, measurement, statistical process control, a focus on process, and a commitment to continuous improvement

Process was especially important to quality management expert Philip Crosby, former vice president of corporate quality for International Telephone and Telegraph, who espoused the value of preventing errors altogether by doing things right the first time Crosby’s “zero defects”

approach to quality improvement set the stage for two other models that focused on eliminating waste: Toyota’s “lean” opera-tions and Six Sigma.14

Toyota’s lean operations, introduced in the 1980s, standardized work processes to avoid wasting resources, time and money

Six Sigma, which Motorola developed in the

late 1980s, also strives to improve ity during the process stage It refers to a statistical measure of variation, but instead

qual-of using percentages, Six Sigma assesses

“defects per million opportunities” and aims for fewer than 3.4 defective parts per million opportunities.15

The Role of NCQA in Improving Quality of Health Care

In the late 1980s, corporate purchasers had fixed on a strategy of the accountable health plan to contain their health care costs Led

by many of the Fortune 500 companies that had adopted the principles of total quality management (e.g., Xerox, Ford, General Motors, Bank of America) or continuous quality improvement, they were seeking to enroll their employees in health plans that would measure their quality and continu-ously improve it In 1988, the National Committee for Quality Assurance (NCQA) changed its governance to put health plans

in the minority on the board, and oped a multistakeholder board, including these corporate purchasers, consumers and quality experts NCQA worked with these corporate leaders and with health plan qual-ity leaders to develop standards for what

devel-a true Hedevel-alth Mdevel-aintendevel-ance Orgdevel-anizdevel-ation would be NCQA’s accreditation standards were developed around many of Deming’s and Juran’s ideas, and the program was launched in 1991

At the same time, NCQA took on a ect that had been developed by a number

proj-of health plans and purchasers to ize quality measurement In 1993, NCQA published its first Health Plan Report Card, using the Healthcare Effectiveness Data and Information Set (HEDIS) For the first time,

standard-it was possible to compare health plans on the effectiveness of care that their members received HEDIS and NCQA accreditation were parallel projects for a number of years

In 1999, NCQA made HEDIS (including standardized patient experience results) an official part of its accreditation program,

History of the Quality Improvement

Movement

and plans’ performance relative to each

other now drive about 40 percent of the

accreditation score

Institute of Medicine Puts New

Emphasis on Quality Improvement

Although the world of health care was

slowly assuming Donabedian’s

structure-process-outcomes approach to quality

improvement, doubts about the

effective-ness of various improvement initiatives

moved Congress in the late 1980s to

commission a study on quality assurance

for Medicare.16 The Institute of Medicine

(IOM) conducted the study, which found

that many health services were

inad-equate In response to the IOM findings,

the Health Care Finance Administration

launched several quality improvement

initiatives during the early 1990s

However, it was the publication of two

IOM reports in 1999 and 2001 that finally

fixed national attention on the critical need

for quality improvement in health care

The first report, To Err is Human: Building

a Safer Health System, magnified the safety

gaps in United States health care, noting

that as many as 98,000 people die yearly

in hospitals due to preventable medical

errors.17 The second report, Crossing the

Quality Chasm: A New Health System for

the 21st Century, (2001), further indicted

the country’s entire health care delivery

system for failing to provide “consistent,

high-quality medical care to all people.”18

Echoing the philosophies of Deming, Juran

and Crosby, the reports blamed the health

care system, instead of individuals, for

widespread errors “Mistakes can best be

prevented by designing the health system

at all levels to make it safer — to make it

harder for people to do something wrong

and easier for them to do it right.”19

The IOM defined quality by what and

how well something is done and attached

it to doing the right thing (delivering the

health care services that are needed), at the

right time (when a patient needs them), and

in the right way (using appropriate tests or

procedures).19

In Crossing the Quality Chasm, the

IOM charged the health care system with frequently lacking “…the environment, the processes, and the capabilities needed

to ensure that services are safe, tive, patient-centered, timely, efficient, and equitable,” qualities it calls “six aims for improvement.” In addition to achiev-ing these aims, the IOM recommended:

effec-improving patient safety and reducing cal error by establishing a national focus

medi-on leadership, research, tools and protocols about safety; expecting mandatory and voluntary reporting of errors; raising safety standards by involving oversight organiza-tions, purchasers and professional societies;

and creating safety systems inside health care organizations.18

Hospital Quality Measurement Leads to Major Improvement

The development and implementation of standardized quality measurement for hos-pitals in the first decade of the 21st century led to substantial improvements in perfor-mance across a wide variety of evidence-based measures The Joint Commission convened experts who reviewed and sum-marized evidence, and produced the first nationally standardized quality measures for hospitals for patients with acute myocardial infarction, heart failure, pneumonia and pregnancy The Joint Commission required all accredited hospitals to collect and report performance data on at least two of these groups of measures in 2002 and began pub-licly reporting the data two years later The Centers for Medicare and Medicare Services (CMS) initiated a program to penalize hospitals financially if they did not report to CMS the same data they were reporting to The Joint Commission and began a public reporting program the next year Both The Joint Commission and CMS programs expanded their reporting requirements over the second half of that decade

Hospitals resisted the collection and reporting of these data at the beginning

The American Hospital Association, the Federation of American Hospitals and the

Quality Improvement

Movement

Association of American Medical Colleges vigorously supported the effort to collect and publish data on nationally standardized measures of hospital quality of care.20 As public reporting increased, hospitals increas-ingly directed resources to improve the clini-cal processes of care in order to enhance performance on the public measures The results have been impressive Throughout the 1990’s, it was not uncommon for hospi-tals to exhibit rates of performance on these quality measures of 40 to 60 percent, with substantial variability among hospitals.21-23

By 2009, hospitals had achieved very high levels of performance on many of these measures, and variation among hospitals was markedly reduced.24 For example, the national average of performance by hospi-tals on discharging eligible acute myocardial infarction patients on a beta blocker was 98.3 percent, up from 87.3 percent in 2002

Also in 2009, on that same measure, fully 96.8 percent of hospitals exhibited rates of performance over 90 percent, compared to 75.2 percent in 2006

In addition, the need for improvement in hospital quality measurement became clear

by 2010 While many measures worked well

to promote improvement activities that led clearly to improved outcomes for patients, others did not In 2010, The Joint Com-mission adopted new criteria that define a higher standard for quality measures that are used in accountability programs such as accreditation, public reporting and pay for performance.25 These criteria are designed

to maximize the likelihood that improved health outcomes will result when hospitals work to improve their performance, while minimizing unintended consequences and the unproductive work that often results when the design of measures makes it easier

to create “paper compliance” than to truly improve clinical care The Joint Commis-sion perinatal care measures, which meet the new criteria for accountability measures, were adopted for voluntary use by hospi-tals in 2009 and are discussed in Chapter

11 of this monograph If widely used by hospitals, they offer the opportunity to greatly improve perinatal care in America’s hospitals by employing this model of measurement-driven improvement, which has already delivered consistent excellence across many valid measures of hospital quality of care

Since the publication of the IOM reports, health care organizations and providers have been exploring ways to improve their practices Many, like those featured in this monograph, are implementing plans designed to reduce errors and improve patient safety and health care quality There will always be concerns about individual blame and the threat of litigation But, as

Toward Improving the Outcome of nancy III illustrates, clinicians are commit-

Preg-ted to improving health care delivery The following chapters will show that improving our system of perinatal care is not just pos-sible; it is happening

History of the Quality Improvement

Movement References

1 Kalisch PA, Kalisch BJ The advance of American nursing (4th ed.) Philadelphia: Lippencott,

Williams & Wilkins, 2004

2 Henry B, Woods S, Nagelkerk J Nightingale’s perspective of nursing administration Sogo Kango

1992;27:16-26

3 Starr P The Social Transformation of American Medicine Basic Books, Inc., 1982:39-124

4 Buchbinder SB, Shanks NH Introduction to Health Care Management Sudbury, MA: Jones and

Bartlett Publishers, Inc., 2007

5 Cooper M Quality assurance and improvement In: LF Wolper (ed.), Health care administration,

Planning, implementing, and managing organized delivery systems Gaithesburg, MD: Aspen

Publishers, Inc., 1999

6 Luce JM, Bindman AB, Lee PR A brief history of health care quality assessment and

improvement in the United States West J Med 1994;160:263-8

7 The Joint Commission A journey through the history of The Joint Commission 2006;2010

8 Johnson KA, Little GA State health agencies and quality improvement in perinatal care

Pediatrics 1999;103:233-47

9 Kolsar P The relevance of research of statistical process control to the total quality movement

Journal of Engineering and Technology Management 1993;10:317-338

10 Shewhart W Economic control of quality of manufactured product New York, NY: Van

Nostrand, 1931

11 Shewhart W Statistical method from the viewpoint of quality control Washington, DC: The

Graduate School of the Department of Agriculture, 1939

12 Juran J The quality trilogy: A universal approach to managing for quality Presented at:

ASQC 40th Annual Quality Congress in Anaheim, California, May 20, 1986

13 Donabedian A Evaluating the quality of medical care 2005;83:691-729

14 Hood L Leddy and Pepper’s Conceptual Bases of Professional Nursing: Seventh Edition

Lippencott, Williams & Wilkins

15 Chassin MR Is health care ready for Six Sigma quality? Milbank Q 1998;76:565,91, 510

16 Lohr KN Medicare: A Strategy for Quality Assurance Washington, DC: National Academy

Press, 1990

17 Institute of Medicine To Err is Human: Building a Safer Health System Washington, DC:

National Academy Press, 2000

18 Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st

Century Washington, DC: National Academy Press, 2001

19 Institute of Medicine Shaping the Future for Health To Err is Human: Building a Safer

Health System 1999

20 Hospital Quality Information Fact Sheet (Accessed September 29, 2010,

at www.aamc.org/quality/jointinitiative/1202hqiifactsheet.pdf.)

21 Jencks SF, Cuerdon T, Burwen DR, et al Quality of medical care delivered to Medicare

beneficiaries: A profile at state and national levels Jama 2000;284:1670-6.

22 Krumholz HM, Radford MJ, Wang Y, et al National use and effectiveness of beta-blockers

for the treatment of elderly patients after acute myocardial infarction: National Cooperative

Cardiovascular Project Jama 1998;280:623-9.

Quality Improvement

Movement

23 Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L

Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction Jama 1997;277:115-21.

24 Improving America’s Hospitals (Accessed September 29, 2010,

at www.jointcommission.org/NR/rdonlyres/D60136A2-6A59-4009-A6F3-04E2FF230991/0/ 2010_Annual_Report.pdf.)

25 Chassin MR, Loeb JM, Schmaltz SP, Wachter RM Accountability measures — using measurement to promote quality improvement N Engl J Med 2010;363:683-8.

chapter title

2

Evolution

of Quality Improvement in Perinatal Care

George A Little, Jeffrey D Horbar, John S Wachtel,

Paul A Gluck, Janet H Muri

Chapter

TIOP I AND TIOP II

In the 1950s and 60s, medical science led

to advances in clinical care of mothers and babies and in public health Hospital care progressed rapidly, with increasing specialization and intensive care units The first newborn care units evolved from early centers for premature babies Rationale for these units included improved outcomes, as interventions, such as treatment of infec-tions, were documented to be effective

Early perinatal clinical trials took place

With recognition that hospital perinatal units improved survival came the study of population-based and regional outcomes

Studies documenting regional variations

in outcomes led to the awareness that further improvements may be possible by better matching needs with the allocation

of resources and the regionalization of subspecialty care

Toward Improving the Outcome of nancy, Recommendations for the Regional

Preg-Development of Maternal and Perinatal Health Services (1976), better known as

TIOP I, was released by an ad hoc Committee on Perinatal Health convened

by the March of Dimes, with tion of the American Academy of Family Physicians, American Academy of Pediatrics (AAP), American College (now Congress)

participa-of Obstetricians and Gynecologists (ACOG) and the American Medical Association The central concept of this landmark publication was a system of regionalized care based on designated levels of care at each facility, supported by an educational organization and a network of inter-hospital transport The document had an immediate and broad impact on perinatal health care delivery by clearly defining the components

of subspecialty care at each hospital level and the “ideal” way each of those levels should interact to provide risk-appropriate care across the continuum of perinatal care.1

As the ability to alter natural biologic processes through individual and lation-based interventions increased, the range of outcomes being monitored expanded • This chapter traces the history of perinatal quality improvement, focusing on advances in perinatal quality improvement (QI) from 1950 through

popu-to the present, primarily in the United States, recognizing this restriction is largely artificial, as perinatal science and health policy are global At this point, one could posit that the domain of perinatal QI starts with preconception and proceeds through to maturity

George A Little, Jeffrey D Horbar, John S Wachtel, Paul A Gluck, Janet H Muri

Toward Improving the Outcome of

Preg-nancy, the 90s and Beyond (TIOP II), the

1993 publication produced by a

reconstitut-ed ad hoc Committee on Perinatal Health,

also convened by the March of Dimes,

broadly expanded the operational definition

of perinatal care to include preconception

through the post-neonatal period Implicit

in TIOP II was the realization that perinatal

care has a direct impact on an individual’s

health long after birth.2

As Table 1 shows, a major difference between TIOP I and II was a strong empha-sis in the latter on data, documentation and evaluation TIOP II, with its broader operational definition of the perinatal period, gave more attention to ambulatory care, while continuing to underscore the need for improvement of hospital care TIOP II also emphasized concepts, such as accountability and availability Quality improvement was a major message and recommendation in TIOP

II, and, as seen in the discussion to follow, it has evolved to be increasingly dynamic in the perinatal care system environment

Evolution of Quality Improvement

Level II — Uncomplicated and majority of complicated

Level III — Uncomplicated and all serious complications

Preparatory and continuing education in regional system

Coordination and communication in regional system

Major task ahead — financing, education, initiating action

TIOP II

1993 Care before and during pregnancy Care during birth and beyond Data documentation and evaluation Financing Health promotion and education Reproductive awareness

Structure and accountability Preconception and interconception care Ambulatory prenatal care

Inpatient patient care Infant care

Improving the availability of perinatal providers Data, documentation and evaluation

Financing perinatal care

Quality Improvement and the Impetus for TIOP III

Evolution of the perinatal health care system from the 1970s to the present is well documented Diverse scientific, system, policy and reimbursement changes increas-ingly came into play during the 1970s, 1980s and 1990s, while the United States implemented a system based upon match-ing the perinatal patient with the most risk-appropriate care and resulting in major improvements in outcomes, such as neona-tal survival rates

As the expansion of beds, manpower and resources continued beyond academic centers and into community hospitals, concerns about the “de-regionalization”

of care and the possible impact on ity began to emerge and, in part, drove the publication of TIOP II Figure 1 displays the modest growth in United States births (14.6 percent) between 1987 and 2008, compared

qual-to the significant growth in neonatal special care beds Improvements in access and

quality may not have mirrored this growth.3

Critical to any current discussion is a mination of what is the right volume and allocation of subspecialty resources, espe-cially in a climate where outside scrutiny

deter-of outcomes and cost deter-of care is likely to increase

Role of Professional Organizations

Many tools, especially health tion technology, have strengthened the ability of care providers and facilities to actively participate in quality improvement Professional organizations representing the many disciplines in perinatal care, includ-ing obstetrics, pediatrics, family medicine, certified nurse midwifery and nursing, have been involved in QI through members and public education to affect change in pro-vider behavior While each organization has a separate governing structure, many have worked collaboratively to improve quality of care by continuing to publish evidence-based research studies and set the

informa-Improvement

in Perinatal Care

Figure 1: Trends in Neonatal Special Care Beds and United States Births 4

standard of care through publications, such

as the TIOP documents and Guidelines

for Perinatal Care, jointly published by

AAP and ACOG every 5 years since 1983

In addition, and in response to numerous

hospital requests for peer-review services of

their obstetrics and gynecology departments,

ACOG established the Voluntary Review of

Quality of Care Program (VRQC) in 1986

The VRQC program provides

confiden-tial peer-review consultation to OB/GYN

departments on request and is completely

voluntary These comprehensive department

reviews are intended to assess quality of care

and patient safety and lead to extensive

rec-ommendations for improvement in patient

care By 2010, the VRQC program had

completed more than 275 hospital reviews,

representing nearly 10 percent of hospitals

in the United States providing obstetrical

services A four-day site visit is scheduled

with a five-person team consisting of three

board-certified OB/GYNs in active practice

who have experience and training in

qual-ity assessment and improvement, a nurse reviewer and a team administrator who is

a professional writer Following a hensive department review, including one full day of interviews and one full day of selected chart reviews, a very detailed, confi-dential final report is produced with findings and recommendations based upon ACOG published guidelines This report is protect-

compre-ed under appropriate state peer-review utes While almost every hospital surveyed has implemented many of the suggested process improvements, the VRQC program has been unable to capture data from the various hospitals documenting improved outcomes as a result of the changes.5

stat-Figure 2 shows how the impact of a professional organization’s recommenda-tions, in this case ACOG, can directly change provider behavior and improve quality The graph depicts the vaginal birth after cesarean section (VBAC) rate (defined

as the rate/100 women with a successful vaginal delivery after previous cesarean

Evolution of Quality Improvement

in Perinatal Care

Figure 2: VBAC Rate by Year 6-10

1 ACOG Committee Opinion No.17 1982

2 ACOG Committee Opinion No 64 1988

3 ACOG Committee Opinion No 143 1994

1 ACOG Committee Opinion No.17 1982

2 ACOG Committee Opinion No 64 1988

3 ACOG Committee Opinion No 143 1994

4 ACOG Practice Bulletin No 2 1998

5 ACOG Practice Bulletin No 5 1999

Improvement

in Perinatal Care

delivery) from 1970 through 2005 The asterisks indicate when significant ACOG publications on the subject were released

The initial 1982 publication was the first to recommend the practice.6 By 1988, ACOG guidelines “encouraged” providers to allow labor for appropriate candidates.7 The 1994 publication reiterated that properly selected women be counseled and encouraged and that an obstetrician be “readily” available.8

By 1998, in response to evidence about potential complications, ACOG recom-mended that women “should be counseled and offered (not encouraged) a trial of labor.”9 In 1999, guidelines suggested that physicians be “immediately” available By

2005, the VBAC rate again approximated the 1985 level.10 In 2010, ACOG published

a further update to its prior tions about VBAC that relaxed some of the previous restrictions.11 It will be interesting

recommenda-to follow any subsequent changes recommenda-to the national VBAC rates based on this update

Role of Government and Regulators

in Perinatal Quality of Care

Federal and state governments, especially after the release of TIOP I, were instrumen-tal in guiding the evolution of the perinatal system and QI efforts Many states readily adopted TIOP I’s level of care definitions in the context of regulations and guidelines, especially with regard to Certificate of Need (CON) applications, thereby driv-ing the expansion of regional systems

Governmental stimulation and support has also included research and program efforts, with collaborative and population-based statewide quality improvement efforts

As a major purchaser of health care services, the government also has significant influence over providers Medicare took the lead in tying improvements in utilization of inpatient care to payments by introducing Diagnosis Related Group (DRG) reimburse-ment in 1983 While perinatal patients clearly fall outside the realm of Medicare reimbursement changes, many payers adopted the DRG reimbursement model for

perinatal care, driving some of the same zation changes As Medicare has evolved, tying reimbursement to the reporting of adult quality metrics, it is only a matter of time (and already occurring in some states) before the public reporting and pay-for-performance

utili-of perinatal quality measures reaches the state Medicaid system The hope is that TIOP III can help drive the perinatal commu-nity to be active participants in that process.The Joint Commission, as the primary accrediting body for most health care facili-ties in the United States, plays a significant role in choosing quality measures that will be reported by hospitals The Joint Commission’s focus has been largely on adult measures in concert with Medicare; however, it recently updated its Perinatal Care (PC) Core Measure Set Among the

17 perinatal measures endorsed by the National Quality Forum (NQF), The Joint Commission selected five: elective delivery, cesarean section, antenatal steroids, health care-associated bloodstream infections in newborns and exclusive breastmilk feeding

Role of Foundations, Collaboratives and other Nonprofit Organizations

Perinatally related goals have been a term primary focus of foundations and nonprofit organizations and a vital force in quality improvement

long-The March of Dimes has played a ship role in this arena since before the publi-cation of TIOP I in 1976.1 While the March

leader-of Dimes is the primary convener leader-of TIOP

I, II, and 3, it is but one of many tions involved in perinatal improvement The Institute for Healthcare Improvement (IHI), a nonprofit organization that works to increase the quality of patient care by intro-ducing improvements throughout the health care system, developed the “Idealized Design

organiza-of Perinatal Care Model” and took a lead role in defining the continuum of high-quali-

ty care, from an informed woman and family

to providing risk-appropriate care in a setting adequately resourced to meet all needs.12

Perinatal medicine has been involved in

the increasingly common multi-institutional

collaborative methodology to improve the

quality and safety of care Two early models

that have informed this approach are IHI’s

Breakthrough Series13 and the Northern New

England Perinatal Quality Improvement

Network.14 Most collaboratives consist of

multidisciplinary teams that work together

with expert faculty to apply quality

improve-ment methods adopted from other industries

to test and implement change ideas designed

to improve care.15 A number of examples,

illustrating the breadth of active

collabora-tive perinatal initiacollabora-tives follow

The Vermont Oxford Network (VON)

conducted the first formal improvement

col-laborative in neonatology in 1995 Analysis

demonstrated measurable improvements in

both chronic lung disease and nosocomial

infections at participating neonatal intensive

care units (NICUs), when compared to a

control group of non-participating NICUs.16

In addition to the clinical improvements,

costs of care of participating NICUs

were reduced, demonstrating that quality

improvement can result in cost reduction.17

Subsequently, VON and other groups have

conducted neonatology collaboratives

addressing a variety of improvements in

quality and safety

Three examples of cluster randomized

trials of collaborative quality improvement

in neonatology are shown in Table 2

The Maryland Perinatal Collaborative is a statewide initiative to test, adopt and imple-ment evidence-based improvement strategies

in obstetric units at hospitals in Maryland and the District of Columbia More than

250 perinatal professionals in hospital multidisciplinary teams conducted a self-assessment and chose the improvement activity that best met its needs Process, out-come and satisfaction measures, along with development of case studies and “improve-ment stories,” were employed Notable improvements in Level I, II and III units were documented, such as a decrease in uterine rupture rate and decrease in returns

to the operating room/labor and delivery

Level III units had a 23 percent decrease in admissions to the NICU for babies > 2500g with a greater-than-24-hour stay.21

State collaboratives, such as the Maryland example, are a dynamic, growing, produc-tive and influential force in perinatal quality improvement Their lineage can be traced in many states to state/regional programs initi-ated immediately after the release of TIOP I

While the original state education programs put in place to improve care have tended to atrophy, they still exist in a few geographic areas and live on in collaboratives that focus on identifying evidence and data for statewide system change or improvement

Evolution of Quality Improvement

Promote surfactant treatment

in preterm infants 23 to 29 weeks Reduce risk of CLD in VLBW infants

Reduction in CLD or nosocomial infections

Findings

Infants in intervention hospitals more likely to receive surfactant in the delivery room

Clinical practice can be changed with Quality Improvement Improvement in both CLD and infection rates

(VLBW: very low birth weight; CLD: chronic lung disease ; NICHD: National Institute of Child Health & Human Development)

Table 2: Cluster Randomized Trials 18-20

Improvement

in Perinatal Care

The Ohio Perinatal Quality tive (OPQC) is another example of a suc-cessful state initiative with diverse strate-gies for quality improvement OPQC was founded in 2007 as a collaboration of pro-viders, payers and state agencies that uses quality improvement methods to improve perinatal health statewide.22 OPQC pub-lishes a monthly graph on its website, communicating across the spectrum of pro-viders as well as consumers, clearly hoping

Collabora-to engage a new audience in the reporting

of quality perinatal outcomes.23

The material in Figure 3, including the caption, is an actual Ohio Perinatal Quality

Collaborative aggregate outcome chart that

is available to the public electronically They are released periodically

Aims for Improvement

The Institute of Medicine’s landmark

publi-cation, Crossing the Quality Chasm: A New

Health System for the 21st Century,

referenc-es the six aims for improvement in care: care that is family centered, safe, effective, equi-table, timely and efficient.24 Figure 4 adds a seventh key domain, social and environmen-tal responsibility, with patients and families

at the center of improvement efforts.25

Figure 3: Ohio Perinatal Quality Collaborative 23

This is the Ohio Perinatal Quality Collaborative’s (OPQC, www.OPQC.net) aggregate control chart for inductions of labor at

36 to 38 weeks gestational age without apparent medical or obstetric indication for 20 Ohio maternity hospitals accounting for 47 percent of Ohio births (Am J Ob Gyn 243.e1-8) The data for this analysis is derived from Ohio birth certificates, which

do not permit exclusion of all indicated inductions For example, abruption as an indication is not reported on birth cates The intervention began September 2008 The centerline (mean) was recalculated, as shown, on two occasions because

certifi-of statistically significant change.

Evolution of Quality Improvement

in Perinatal Care

Conclusion and Recommendations

This chapter has provided a history of

peri-natal quality improvement There has been

great progress, as well as many

develop-ments that provide encouragement for the

future The continuing expansion of

multi-hospital collaboratives will greatly improve

the rapid dissemination of evidence-based protocols and processes There are, of course, challenges to be addressed, as well

as the following recommendations:

1 State regulatory agencies should try to adopt a standard definition of levels

of perinatal care, to enhance quality improvement by allowing comparisons

of outcomes across units within and across states and to enable providers

to assess and be held accountable for population-based perinatal outcomes (total cohort accountability).26

2 Use of The Joint Commission Perinatal Care Core Measure Set should be encouraged and incentivized Use and measurements of other National Quality Forum-endorsed perinatal measures also should be encouraged

3 Patients and families should be offered the opportunity to participate in all qual-ity improvement initiatives

The legacy of improving perinatal outcomes stated so clearly in TIOP I is a dynamic pro-cess that has matured in sophistication and productivity Evolution of commitment and methodology will continue across all current collaborators, and the growing inclusion

of patients and their families in the process shows great promise

Figure 4: Seven Key Themes for Quality

Improvement 25

Seven key themes for quality improvement used by the

Vermont Oxford Network NICQ Collaboratives (adapted

from reference 25, reprinted with permission from the

Vermont Oxford Network)

Safe

Family Centered Safe

References

1 Committee on Perinatal Health Toward Improving the Outcome of Pregnancy:

Recommendations for the Regional Development of Maternal and Perinatal Health Services

White Plains, NY: March of Dimes National Foundation, 1976

2 Committee on Perinatal Health Toward Improving the Outcome of Pregnancy: The 90s and

Beyond White Plains, NY: March of Dimes National Foundation, 1993

3 Goodman DC, Fisher ES, Little GA, Stukel TA, Chang CH, Schoendorf KS The relation between

the availability of neonatal intensive care and neonatal mortality N Engl J Med 2002;346:1538-44

4 AHA Reports and Studies American Hospital Association, 2010

5 Lichtmacher A Quality assessment tools: ACOG Voluntary Review of Quality of Care Program,

Peer Review Reporting System Obstet Gynecol Clin North Am 2008;35:147,62

10 ACOG practice bulletin Vaginal birth after previous cesarean delivery Number 5, July

1999 (replaces practice bulletin number 2, October 1998) Clinical management guidelines for obstetrician-gynecologists American College of Obstetricians and Gynecologists Int J Gynaecol Obstet 1999;66:197-204

11 ACOG Practice bulletin no 115: Vaginal birth after previous cesarean delivery Obstet Gynecol 2010; 116:450-63

12 About Us Institute for Healthcare Improvement, 2010

13 The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement In: IHI Innovation Series white paper Boston, MA Institute for Healthcare Improvement, 2003

14 Northern New England Perinatal Quality Improvement Network NNEPQIN Mission

2010

15 Hughes R Patient and Safety Quality: An Evidence-Based Handbook for Nurses In: Tools and Strategies for Quality Improvement and Patient Safety Rockville, MD: Agency for Healthcare Research and Quality (US), April 2008

16 Horbar JD, Rogowski J, Plsek PE, et al Collaborative quality improvement for neonatal intensive care NIC/Q Project Investigators of the Vermont Oxford Network Pediatrics 2001;107:14-22

17 Rogowski JA, Horbar JD, Plsek PE, et al Economic implications of neonatal intensive care unit collaborative quality improvement Pediatrics 2001;107:23-9

18 Horbar JD, Carpenter JH, Buzas J, et al Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial Bmj 2004;329:1004

19 Walsh M, Laptook A, Kazzi SN, et al A cluster-randomized trial of benchmarking and multimodal quality improvement to improve rates of survival free of bronchopulmonary dysplasia for infants with birth weights of less than 1250 grams Pediatrics 2007;119:876-90

20 Lee SK, Aziz K, Singhal N, et al Improving the quality of care for infants: a cluster randomized controlled trial Cmaj 2009;181:469-76

21 The Maryland Hospital Association and Delmarva Foundation for Medical Care Creating

a foundation of excellence: Five years of innovation in patient safety Maryland Patient Safety Center 2008 Annual Report 2008

22 Donovan EF, Lannon C, Bailit J, Rose B, Iams JD, Byczkowski T A statewide initiative to reduce inappropriate scheduled births at 36(07)-38(6/7) weeks’ gestation Am J Obstet Gynecol 2010;202(3):243 e1-8

23 Ohio Perinatal Quality Collaborative Monthly Graphs

Epidemiologic

Trends in Perinatal Data

Vani R Bettegowda, Eve Lackritz, Joann R Petrini

Chapter

Perinatal Trends

A robust national vital statistics system

is imperative to assess trends in perinatal health and identify emerging issues that require further investigation and response

Perinatal data as reported from birth and death certificates are fundamental to monitoring the well-being of mothers and infants in the United States The majority of perinatal data presented in this chapter are from the National Vital Statistics System, National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) Infant mortality rates presented are from the birth/infant death data set, which contains information from the birth certificate linked to the infant’s death certificate, allowing for more in-depth analyses of trends In 2003, the United States Standard Certificate of Live Birth was revised to include additional detailed information on pregnancy health, risk fac-tors and birth outcomes By 2009, only 30 states, District of Columbia and New York City had implemented the 2003 revised United States Standard Certificate of Live Birth, hindering the ability to compare temporal and regional prenatal care and delivery method data, as well as new data items, such as trial of labor and admission

to neonatal intensive care units (NICUs)

Infant Deaths

Infant mortality is a commonly accepted indicator of the overall well-being and health of a nation In the United States, approximately two-thirds of infant deaths occur in the neonatal period (the first month

of life).1 Despite a marked decrease in the last century, infant mortality rates remained relatively stable and declined only 3 percent between 2000 and 2006 (6.9 and 6.7 per 1,000 live births, respectively).1 Although neonatal mortality rates declined dramati-cally in the 1970s to the 1990s primarily due to advances in neonatal critical care, neonatal mortality rates remained essen-tially unchanged in recent years (4.6 and 4.5 per 1,000 live births in 2000 and

2006, respectively) (Figure 1).1, 2 Rates of postneonatal mortality (deaths of infants between 28 and 364 days of life) also remained relatively stable between 2000 and 2006 (2.3 and 2.2 per 1,000 live births, respectively).1,2

For more than two decades, birth defects have been categorized as the leading cause

of infant mortality, followed by ty/low birthweight not elsewhere classified.” Prematurity/low birthweight is the leading cause of infant death among black infants and the most common cause of neonatal mortality overall Infant deaths due to

Vani R Bettegowda, Eve Lackritz, Joann R Petrini

Epidemiologic Trends

in Perinatal Data

A neonatal death occurs in the first 28 days of life A postneonatal death occurs between 28 days and one year of life.

Source: Na�onal Center for Health Sta�s�cs, 1960-1990 final mortality data, 1995-2006 period linked birth/infant death data.

Prepared by the March of Dimes Perinatal Data Center, 2010.

Figure 1 Infant, Neonatal, Postneonatal Mortality

United States, 1960-2006

Figure 1: Infant, Neonatal, Postneonatal Mortality, United States, 1960-2006

A neonatal death occurs in the first 28 days of life A postneonatal death occurs between 28 days and one year of life

Source: National Center for Health Statistics, 1960-1990 final mortality data, 1995-2006 period linked birth/infant

death data

Prepared by the March of Dimes Perinatal Data Center, 2010.

prematurity/low birthweight increased

approximately 5 percent between 2000

and 2006 (108.4 to 113.5 per 100,000 live

births), while deaths due to birth defects

decreased more than 3 percent during this

same period (141.8 to 137.1 per 100,000

live births).1,2 Preterm-related causes, a

recently developed grouping of causes of

death intended to more fully capture the

impact of preterm birth as the underlying

cause of infant deaths, accounted for more

than one-third (36.1 percent) of infant

deaths.1 At least one-third of postneonatal

deaths are due to potentially preventable

causes of death, including sudden infant

death syndrome (SIDS), injuries and

infec-tions.3 However, identifying effective

strategies to prevent preterm birth, the most

frequent cause of death during the neonatal

period, will require continued research

Fetal Deaths and Perinatal Mortality

Fetal deaths, spontaneous intrauterine death regardless of the duration of pregnancy, are

a significant reproductive concern, with an estimated 1 million fetal deaths reported annually in the United States.4 Fetal deaths

at 20 weeks of gestation or more, often termed “stillbirth,” affect approximately

1 in 160 deliveries.5 Yet, fetal deaths have not been studied as closely as infant deaths and, consequently, are poorly understood

There are varying definitions of perinatal mortality, and NCHS reports trends for two different definitions Perinatal mortal-ity definition I, defined as infant deaths at less than seven days of age and fetal deaths

at 28 or more weeks gestation, is used for international and state comparisons to account for variations of completeness in reporting fetal deaths at 20 to 27 weeks gestation Perinatal mortality definition II

Epidemiologic Trends

in Perinatal Data

is more inclusive and includes infant deaths

at less than 28 days of age and fetal deaths

at 20 or more weeks gestation Definition

II is helpful in monitoring perinatal ity rates throughout the gestational period, since most fetal deaths occur before 28 weeks gestation.4

mortal-Fetal mortality rates (fetal deaths of 20 weeks of gestation or more) decreased 17 percent between 1990 and 2003, from 7.5

to 6.2 per 1,000 live births and fetal deaths, primarily due to a decrease in the number

of reported late fetal deaths (28 weeks of gestation or more) Fetal mortality rates did not decline significantly between 2003 and

2005 (Figure 2).4 In 2005, there were 25,894 fetal deaths (20 weeks of gestation or more), almost equal to the number of infant deaths (28,384 infant deaths in 2005)2,4

Neonatal deaths and stillbirths may have similar root causes, and perinatal mortality rates are calculated to monitor both of these obstetric events around the time of delivery

For both definitions, there was a decrease

in perinatal mortality rates between 1990 and 2003, and rates remained relatively

unchanged between 2003 and 2005 There was a steeper decrease in the perinatal mortality rate for definition I, since almost all of the decrease in fetal deaths occurred among late fetal deaths.4 For definition I, the perinatal mortality rate decreased 25 percent between 1990 and 2003 (from 9.0

to 6.7 per 1,000 live births and fetal deaths) and remained stable at 6.6 in 2005; while, for definition II, the perinatal mortality rate decreased 17 percent between 1990 and 2003 (from 13.1 to 10.8 per 1,000 live births and fetal deaths) and also remained relatively unchanged at 10.7 in 2005.4

More than half (58 percent) of all tal deaths in the United States are fetal deaths occurring at 20 weeks of gestation or more, but less is known about their incidence and etiology.4 Challenges to the reliability and quality of fetal death data include differences

perina-in state reportperina-ing requirements and the pleteness of fetal death certificate reporting.4,6

com-Improved and consistent reporting of fetal deaths is needed to understand the underly-ing risks associated with perinatal death and strategies for prevention

Figure 2: Fetal Mortality Rates by Gestational Age United States, 1990-2005

Total 20-27 weeks 28 weeks or more

United States, 1990- 2005

Source: National Center for Health Statistics, fetal death data.

Epidemiologic Trends

in Perinatal Data

Further investigation

of short-term and long-term outcomes of infants stratified

by gestational age

is needed to guide optimal obstetric and neonatal management.

Figure 3 Preterm Births by Gesta�onal Age,

United States, 1981-2008*

*Preliminary 2008 gesta�onal age categories do not sum to total due to rounding.

Very preterm is less than 32 completed weeks gesta�on Late preterm is between 34 and 36 weeks gesta�on.

Preterm is less than 37 completed weeks gesta�on

Source: Raju TN Epidemiology of late preterm (near-term) births Clin Perinatol 2006;33(4):751–63.

Na�onal Center for Health Sta�s�cs, final natality data and 2008 preliminary natality data.

Prepared by the March of Dimes Perinatal Data Center, 2010.

*Preliminary 2008 gestational age categories do not sum to total due to rounding

Very preterm is less than 32 completed weeks gestation Late preterm is between 34 and 36 weeks gestation

Preterm is less than 37 completed weeks gestation

Sources: Raju TN Epidemiology of late preterm (near-term) births Clin Perinatol 2006;33(4):751–63

National Center for Health Statistics, final natality data and 2008 preliminary natality data

Prepared by the March of Dimes Perinatal Data Center, 2010.

Figure 3: Preterm Births by Gestational Age, United States, 1981-2008*

Gestational Age

Preterm birth (less than 37 completed weeks

gestation) is a serious clinical and public

health problem, affecting more than half a

million births in the United States each year,

or 1 in every 8 births Rates of preterm birth

have increased 35 percent since 1981 (9.4

percent to 12.7 percent in 2007).7 Infants

born prematurely are at increased risk for

newborn death and morbidity, including

respiratory problems and developmental

delays Estimates of societal economic costs

associated with preterm birth total more

than $26 billion annually.8

Infants born very preterm (less than 32

weeks completed gestation) are at greatest

risk of death and long-term disability and

accounted for 2.0 percent of live births in

2007.7 During the last two decades, rates

of very preterm birth have remained steady,

while late preterm births (between 34 and

36 weeks gestation) increased 43 percent

(6.3 percent in 1981 to 9.0 percent in

2007).7,9 However, 2008 preliminary data

suggest a decline in rates of late preterm and preterm births (8.8 percent and 12.3 percent

in 2008, respectively) (Figure 3).10 Late preterm births comprise more than 70 per-cent of all preterm births and are the fastest growing subgroup of preterm births.11 Compared to term infants, these infants have a higher incidence of morbidity, includ-ing respiratory distress syndrome, tempera-ture instability and jaundice and have three times the infant mortality rate.12,13 Late preterm births require more resources than term births, such as longer hospital stays and higher hospital costs associated with NICU admissions.14

The gestational age distribution of term births (37 to 41 completed weeks gesta-tion) has changed since the 1990s Between

1990 and 2007, births at 37 and 38 weeks gestation increased 45 percent (from 19.7 percent to 28.6 percent of all live births), while births at 40 and 41 weeks gestation decreased by 26 percent, (from 36.7 percent

to 27.2 percent of all live births).15 Recent

in Perinatal Data

evidence shows disparate birth outcomes for infants born at 37 and 38 weeks gesta-tion, compared to infants born at 39 and

40 weeks gestation A study by Zhang and Kramer16 revealed that despite a low abso-lute risk of infant death at term, singleton infants born at 37 weeks had increased neo-natal mortality rates, compared to infants born at 40 weeks (0.66 and 0.34 per 1,000 live births, respectively) Recent studies

of elective deliveries found increased rates

of respiratory problems and admission to NICUs for infants born at 37 and 38 weeks, compared to those born at 39 weeks.17,18

Further investigation of short-term and long-term outcomes of infants stratified by gestational age is needed to guide optimal obstetric and neonatal management

43 percent of preterm births also are born low birthweight, and nearly 67 percent of low birthweight infants are born preterm.15

In 2007, 8.2 percent of live births, or 1 in

12 infants, were born low birthweight and 1.5 percent of infants were born very low birthweight (<1500 grams or 31⁄3 pounds) in the United States.7 In the past two decades, rates of low birthweight have increased

21 percent (from 6.8 percent in 1981

to 8.2 percent in 2007), and rates of very low birthweight have increased 25 percent (1.2 percent in 1981 to 1.5 percent in 2007).7 According to 2008 preliminary birth data, rates of low birthweight and very low birthweight remained unchanged (8.2 per-cent and 1.5 percent, respectively).10

Low-birthweight infants are at increased risk for neonatal morbidities, long-term disability and death.19 Very low-birthweight infants are more than 100 times as likely and low-birthweight babies are more than

25 times as likely to die in the first year of life compared with infants not born

low birthweight.3 Although improvements

in neonatal care19 have increased infant survival, research is needed to address the underlying causes of low birthweight and its relationship to preterm birth, in order to reverse increasing low-birthweight trends

defini-or its management, but not from accidental

or incidental causes.”20 After a period of steep decline following the 1950s, when the maternal mortality rate was approxi-mately 83 deaths per 100,000 live births, maternal deaths in the United States began

to increase between 2002 and 2006 (8.9 to 13.3 per 100,000 live births) (Figure 4).21

In 2002, a new question was added to the Standard Certificate of Death to utilize addi-tional codes identified in the International Classification of Diseases, tenth revision (ICD-10) for deaths related to pregnancy, and facilitated the identification of late maternal deaths, deaths caused by preg-nancy that occurred from 43 days to 1 year postpartum.22 The addition of a separate pregnancy status question on the death certificate in 2002 resulted in an increase in the reported maternal mortality rate.22

Maternal mortality rates will likely increase, as more states adopt the revised death certificate In addition, a recent study in Maryland found that enhanced surveillance efforts, which include linking maternal death certificates with infant birth and fetal death records, along with review

of medical examiner records and death certificates, led to higher reported maternal mortality rates than information from death records alone.23 Nationally, enhanced ascertainment through CDC’s Pregnancy